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Marvelous yet fragile: When do disabilities become disabling?

The human condition is marvelous yet fragile. Very recently, for example, athletes such as Usain Bolt, Michael Phelps and Simone Biles dazzled the world with Olympic heroics.

Yet such supreme prowess can be very fleeting. Accidents and illnesses can strike even the fittest and most vibrant of people. For athletes with disabling conditions, the Paralympics -- which are going on now in Rio - offer a forum for perseverance and possibility. But the difficult and often excruciating challenges of people who experience disabling conditions cannot be denied.

Sometimes those challenges include struggles with insurance companies who deny coverage on long-term disability policies. In this post, we will use a Q & A format to discuss how these companies often try to shamefully sidestep their obligation to honor the policies they so readily accepted premiums for.

What is the definition of long-term disability?

The meaning of the term "long-term disability" depends on the context in which it is used.

One context is Social Security disability law. Another is workers' compensation.

Long-term disability insurance is another key context. This insurance can be provided through an employer or purchased privately.

For long-term disability insurance, what kind of tactics do insurance companies use to try to deny benefits?

Unethical insurance companies tend to try to keep the definition of disability squishy when getting a physician's opinion about a claimant's condition.

For example, the company may broadly ask the doctor whether the claimant has any work restrictions, without defining what type of work is meant.

Or the company may try to reduce a job to a checklist of duties, implying that someone isn't disabled if he or she can do some of the duties.

This is not really a fair way to define total disability because only being able to do a few of the tasks wouldn't enable the person to actually do the job in practice. Indeed, this would still be true even with some accommodation by the employer.

Do doctors know what to look for when making determinations about disability?

Not always. Sometimes doctors face difficult dilemmas between trying to maximize the patient's recovery, on the one hand, and admitting that it's time to document the disabilities, on the other. Unscrupulous insurance companies try to take advantage of this tension in how physicians approach examinations of people dealing with disabilities.

Is the distinction between "total disability" and "partial disability" important?

Again, one must be clear on the context for the question. Those terms are also used in the law of workers' comp. But in the field of disability insurance, insurance companies may try to imply that "total disability" means not being able to work at all. That is not necessarily the case.

What about the difference between "any occupation" and "own occupation" insurance coverage?

This is an important distinction in insurance law. In California, state law sets out a definition of what disability means for each of those two types of coverage. Under well-established case law, this definition applies regardless of how the insurance policy itself tries to define disability.

What to do if the insurance company plays games

Insurance companies are prone to game-playing when it comes to definitions of long-term disability. If you are concerned that you are being jerked around, it's important to get strong legal counsel from an attorney skilled in this complicated area of the law.

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